Vaginal Hysterectomy; a Review of Sixty=six Consecutive Cases. BY CHARLES GILBERT DAVIS, M.D. CHICAGO, ILL. REPRINTED FROM THE JOURNAL OF THE AMERICAN MEDICAL ASSOCIATION, SEPTEMBER 18, 1897. C CHICAGO: American Medical Association Press. 1897. Vaginal Hysterectomy; a Review of Sixty-six Consecutive Cases. VAGINAL HYSTERECTOMY; A REVIEW OF SIXTY-SIX CONSECUTIVE CASES. Whatever adds to the health of woman tends directly to increase the happiness of the human race. On her physical condition hangs the destiny of nations. The truthfulness of this assertion is instinc- tively recognized by the medical world. Hence, vol- umes have been written, and a controversial warfare has been waged for centuries in an endeavor to elucidate her diseases and relieve her suffering. So bitter have been these conflicts in regard to the pathology of her ailments and their treatment, that the pelvic cavity may well be called the battle-ground of medical science. Every generation, every decade, sees new triumphs in the direction of truth. The last quarter of a cen- tury has witnessed a revolution in the surgery relat- ing to the pelvic region. While general surgical methods have made a very decided advance, it must 'Figure 1.-Beginning oe First Stage. 4 be conceded that some of the greatest triumphs have been achieved by improved operative measures em- ployed to relieve many of the various pathologic con- ditions of the uterus and the adnexa. In the ablation of the uterus, ovaries and tubes much controversy has existed and still continues as to whether the abdomi- nal or vaginal route afford the best results for equal conditions. The discussion, pro and con, has been extensive for the last three years and has augmented to the extent of many volumes. As with all subjects of like nature, there are a few salient points upon which the question hinges. My own observations are made after having witnessed these operations per- formed by some of the most skilled gynecologists of same could not be done by the vaginal method. There are growths, solid and cystic, -of the tubes, ovaries and uterus, which we find impossible to remove per vaginam, but even here, in many instances, when the uterus has to be removed, I believe the percentage of deaths will be less if we begin or finish the operation through the vagina. „ The question as to the advisability of allowing the uterus to remain when it becomes necessary to remove both ovaries, seems to me to have but little argu- ment in its favor. We know full well that in a major- ity of instances the inflamed conditions that lead to the necessity of most of these operations have their incipiency in the lining membrane and other tissues Figure 2.-! -Second Stage. Europe, and then verifying their methods by personal experience. I am satisfied that each of these methods has its sphere of usefulness, and the broad-minded, unprejudiced surgeon will not be slow in making the application. The general of an army who relies at all times and under all circumstances on a single plan of battle, will ultimately meet a most inglorious defeat. The successful man knows that frequently, on- the instant, it becomes necessary for him to change his method of operation. Taking all things into consid- eration, I am satisfied that for most pelvic operations the vaginal route offers by far the best results. With the statistics that we now have, I should regard it as unsurgical and unwise in the extreme to perform any operation on the pelvic viscera abdominally, when there are no logical reasons or indications why the I of the uterus. If then we stop at the removal of the ovaries we leave behind the real center of disease as the nidus or hatching place of diseased germs, which are liable to prove disastrous in the future. In my opinion, much nonsensical argument has been wasted on this subject. The uterus is simply service- able in the process of child-bearing. After the ovar- ian ablation, its usefulness as an organ terminates and it becomes a superfluous and foreign body. I have no sympathy for the sentimentality that weeps over the removal of a permanently diseased uterus. It is far better to make these operations thorough, speedy and complete, than to remove a portion and leave the remainder to cause years of suffering or perhaps neces- sitate the ordeal of another operation. I have never, removed a uterus for which I felt 5 regret. I have allowed several to remain that I am sure ought to have been removed. I have never known vaginal hysterectomy to be followed by hernia. The vaginal vault seems as strong or stronger than when occupied by the weighty and diseased organ. The sex- ual function in the mature woman is certainly not im- mediately diminished. I know of several instances where the removal of the diseased organ has caused an augmentation of the sexual sensibility. As a rule it is therefore safe to say, when we have to remove the ovaries, remove also the uterus, and do it per vaginam. ligatures and then witnessing the operation with clamps by Pean, I have not hesitated to adopt the latter method and have never deviated from it. In my sixty-six cases I have never had occasion to tie a single ligature. Only once has hemorrhage followed the removal of the clamps at the expiration of forty-eight hours. This was from the right uter- ine artery, and was easily clasped by a clamp which was allowed to remain on forty-eight hours longer. In another case hemorrhage occurred during a dres- ing on the eighth day, caused probably by too great Figure 3.-Operation Complete. The operation may be divided into three stages: 1, The cervix is encircled by an incision and the entire organ is denuded anteriorly and posteriorly, as far as practicable; 2, the uterine arteries are clamped and the uterus is enucleated, or if that is impractical, it is removed by morcellation; 3, the ovarian arteries are secured and the uterus together with tubes and ovaries is cut away. The technique of the operation I have de- scribed in my article in the Journal of Feb. 8, 1896, where I reported the first twenty-two cases of this series. After observing the German method of operating with distension of the vagina with speculum by the nurse. It was not severe and yielded to hot douches. In another case an intestinal fistula manifested itself on the ninth day. This continued for about six weeks and then healed spontaneously. I am satisfied that many accidents of hernia, fistula, secondary hem- orrhage, etc., are caused by unnecessary distension of the vaginal walls with dressings. Now, after the removal of the clamps, I never allow a speculum to be inserted until the wound is entirely healed. The cavity is douched once daily, taking care not to allow 6 the fluid to enter the abdominal cavity, and the mouth of the vagina is distended lightly with two fingers and the parts dusted with- powdered iodoform, and a small strip of gauze inserted to the depth of two inches. The external genitalia are again dusted with the powdered iodoform and a strip of gauze folded over the parts. A T bandage is adjusted and the dressing is complete. An early evacuation of the bowels expedites the prog- ress of the case. This is usually done by an enema day or a week that by letter or conversation I do not hear expressions of gratitude for complete relief from suffering following the operation. How often we all have been chagrined and disap- pointed by the opposite expressions that so frequently come to us after having done our best to relieve the patient by removing a tube, an ovary, or both, through the abdominal route. In many of these cases the removal of diseased structures was not complete and the day following the removal of the forceps. Men- strual storms are certainly modified by an early and prolonged administration of ovarian extract. The patient usually makes rapid recovery. There certainly is no other capital operation known for women to which we may so conscientiously and truthfully after our treatment apply the term "cure." There is not a Figure 4.-Dressings. disease still lingered. If I should formulate the rules indicating the operation of vaginal hysterectomy, they would be somewhat as follows: 1. In all cases of malignant uterus where the dis- ease has not advanced too far in the pelvic walls. 2. In maturely developed women where we deter- mine to remove both ovaries or tubes. 7 3. In removal of one ovary when also the uterus shows evidence of long standing inflammatory action. 4. In all cases nearing the menopause suffering from chronic painful displacement. 5. In all cases of fibroid not to exceed the size of a child's head and involving seriouly the integrity of the uterine walls. finish the operation through the abdomen. But it is certainly not detrimental to have made this beginning. In fact, whenever we perform abdominal hysterectomy the most rational procedure is to begin or terminate the operation by clamping the uterine arteries and removing the cervix through the vagina. Twice I have attempted the vaginal operation and been com- pelled to open the abdomen. In one case the entire 1 Ether and Suggestion. Result. | Number. Name. Pathologic Condition. Hospital. Ether. Recovered. 1 s Subsequent history. 1 Mrs. E. E.. . . Fibroid Chicago Baptist.. 1 1 Recovery Complete. 2 Mrs. T. D.. . . Fibroid Chicago Baptist.. 1 1 Pelvic symptoms disappeared; suffered heart disease. 3 Mrs. J. b . . . Fibroid Chicago Baptist.. 1 1 Recovery complete. 4 Mrs. W. K. . . Metritis, chronic Chicago Baptist.. 1 1 Recovery complete. 5 Mrs. F. J . . . Cystic ovaries St. Mary's Polish. 1 1 Hemorrhage at end 2d week. Recovery complete. 6 Mrs. A. F. M. . Fibroid Chicago Baptist.. 1 1 Recovery complete. 7 Mrs. C. L. M. . Fibroid with cystic ovaries Chicago Baptist.. 1 1 Recovery complete. 8 Mrs. C. H.. . . Fibroid Chicago Baptist.. 1 1 Recovery complete. 9 Mrs. W.M. N.. Cystic ovaries Chicago Baptist.. 1 1 Recovery complete. 10 Mrs.E.W. C. . Salpingitis with metritis Chicago Baptist.. 1 1 Recovery complete. 11 Mrs. B. L.. . . salpingitis Chicago Baptist.. 1 1 Recovery complete. 12 Mrs. E. A.S . . Ovaritis, chronic Chicago Baptist.. 1 1 Recovery complete. 13 Mrs. J.O.r. . Carcinoma Chicago Baptist.. 1 1 No return of disease. Health perfect. 14 Miss M.S.. . . Cystic ovaries Chicago Baptist.. 1 1 Health improved, but still nervous. 15 Mrs W. N. M. . Salpingitis Chicago Baptist.. 1 1 Recovery complete. 16 Miss L. P . . . Metritis and salpingitis Chicago Baptist.. 1 1 Pelvic symptoms relieved; nervous. 17 Mrs. M. L.. . . Carcinoma St. Mary's Polish. 1 1 Recovery complete. 18 Miss D. M. K.. Cystic ovaries Chicago Baptist.. 1 1 Recovery complete. 19 Mrs. J. L . . . Cystic ovaries St. Mary's Polish. 1 1 Hemorrhage on removal clamps, 48 hours. Parotiditis. Recovery complete. 201 Miss M. B. . . Pyosalpinx Metritis, chronic Chicago Raptist.. 1 1 Recovery complete. 21 Mrs. M. M. G.. Chicago Baptist.. 1 1 Recovery complete. 22 Miss M . . . . Fibroid St. Joseph's .... 1 1 Vomiting. Death from exhaustion 36 hours. 23 Miss L. H. . . Cystic ovaries Chicago Baptist.. 1 1 Recovery complete. 24 Miss L. H. . . Fibroid Chicago Baptist.. 1 1 Recovery complete. 25 Miss CP... Metritis and large cyst of right ovary. Chicago Baptist.. 1 1 Recovery complete. 26 Mrs.F. C. C. . Cystic ovaries Chicago Baptist.. 1 1 Recovery complete. 27 Mrs. C. G.. . . Carcinoma Chicago Baptist.. 1 1 Recovery complete apparently. 28 Miss L. M. . . Fibroid Chicago Baptist.. 1 1 Recovery complete. 29 Mrs. W . . . . Fibroid Chicago Baptist.. 1 1 Recovery complete. 30 Mrs. J. V . . . vfetritis, chronic Chicago Baptist.. 1 1 Recovery complete. 31 Mrs. M . . . . Fibroid and large cyst of right ovary. Chicago Baptist.. 1 1 Recovery complete. 32 Mrs. S Fibroid Chicago Baptist.. 1 1 Recovery complete. 33 Miss W . . . . Fibroid Chicago Baptist.. 1 1 Recovery complete. 34 Mrs. J. L . . . Fibroid Chicago Baptist.. 1 1 Recovery complete. 35 Mrs. S. K . . . Pyosalpinx Fibroid • • • Chicago Baptist.. 1 1 Recovery complete. 36 Mrs. J. B . . . Chicago Baptist.. 1 1 Recovery complete. 87 Mrs. F Prolapsus of twenty years Waunita, Colo . . 1 1 Recovery complete. 38 Mrs. G.N. F . Metritis, chronic Chicago Baptist.. 1 1 Recovery complete. 39 Polish woman Cystic ovaries St. Mary's Polish. 1 1 Recovery complete. 40 Mrs. L Cystic ovaries, large cyst right ovary. Chicago Baptist.. 1 1 Recovered slowly. Fistula discharge; fistula tract, 2d operation, removed small section fallopean tube. 41 Miss G. W. . . Cystic ovaries . ... ......... Chicago Baptist.. 1 1 . . Recovery complete. 42 Miss E. 8.. . . Large cysts of both ovaries Chicago Baptist.. 1 1 . . Recovery complete. 43 Mrs. M . . . . Metritis, chronic Chicago Baptist.. 1 1 . Recovery complete. 44 Miss L. D . . . Metritis, chronic Chicago Baptist.. 1 1 . . Recovery complete. Still nervous; pelvic symptoms entirely relieved. 45 Miss E. P.. . . Metritis, cystic ovaries Chicago Baptist.. 1 1 . Recovery complete. 46 Miss F. F. B .. Fibroid Chicago Baptist.. 1 1 . . Recovery complete. 47 Miss M. B. . . Cystic ovaries Chicago Baptist.. 1 1 . . Recovery complete. 48 Mrs. E. C.. . . Fibroid Chicago Baptist.. 1 1 Recovery complete. 49 Mrs. M. R. 8.. Metritis, chronic Chicago Baptist.. 1 1 Recovery complete. 50 Mrs. P. M„. . Cystic ovaries Chicago Baptist.. 1 1 Recovery complete. 51 Mrs. C. D. F... Metritis, chronic Chicago Baptist.. 1 1 Recovery complete. 52 Mrs. L Cystic ovaries Chicago Baptist.. 1 1 Recovery complete. 58 Mrs. C. G.. . . Cystic ovaries Chicago Baptist.. 1 1 Recovery complete. 54 Mrs. G. L . . . Cystic ovaries Chicago Baptist.. 1 1 Recovery complete. 55 Mrs. A. M. H.. Fibroid Chicago Baptist.. 1 1 Recovery complete. 56 Mrs. S. . . . Fibroid and cyst of right ovary. . . . Chicago Baptist.. 1 1 Recovery complete. 5< Mrs C Fibroid Chicago Baptist.. 1 1 Recovery complete. 58 Mrs. J. F . . . Fibroid Chicago Baptist.. 1 1 Recovery complete. 59 Mrs. S Salpingitis Chicago Baptist.. 1 1 Recovery complete. 60 Mrs. J. S. . . . Metritis, chronic Chicago Baptist.. 1 1 Recovery complete. 61 Mrs V Cystic ovaries Chicago Baptist.. 1 1 Recovery complete. 62 Mrs. W . . . . Multiple flbioma of uterus, dermoid Chicago Baptist. 1 1 . . Recovery complete. cyst left ovary and broad ligament. Recovery complete. 63 Miss M. C. L . Fibroid tumor Chicago Baptist . 1 1 64 Mrs. L Large hydrosalpinx right side, cystic ovaries and chronic metritis .... Chicago Baptist . 1 .1 Recovery complete. 65 Miss S Anteflexion, fibroid degeneration of Chicago Baptist. 1 1 Recovery complete. fundus of uterus, cystic right ovary. Recovery complete. 66 Mrs. A. J. M. . chronic metritis Chicago Baptist. 1 6. In double pyosalpinx and in single if uterus is badly diseased. 7. Whenever from any cause, specific or otherwise, the uterus has been chronically diseased, has long resisted other treatment and proved a center of serious reflex symptoms. It is not infrequently the case that we begin a vaginal hysterectomy and, owing to adhesions or other causes, are compelled to abandon this method and pelvic viscera were cemented in a mass of chronic inflammation. I removed a greater portion of the mass with the uterus per vaginam and ruptured the bladder, which I subsequently closed by producing occlusion of the vagina. Again, I attempted to remove a myoma the size of a child's head through the vagina. I took away by morcellation the cervix and greater portion of the body of the uterus and clamped the uterine arteries, but the hemorrhage from above be- 8 most powerful fortifiers of the nervous system, and I strongly believe there is no one single thing more calculated to insure the successful termination of a surgical operation than the employment of suggestion as the patient passes into the sleep of anesthesia. It is interesting to note that in the case of the one death occurring in this series, and the other cases of post- operative accident no suggestion was employed. Every surgeon should be thoroughly impressed with the fact that faith, hope, expectancy and belief, when aroused by suggestion, are most powerful aids to insure his patient against collapse and death. With this clearly before him and a determination to observe every minutia and care, he is in the best possible way to operate successfully. 240 Wabash Avenue. came so profuse that I was compelled to finish through the abdomen. I only had to ligate the ovarian arter- ies, dissect the anterior and posterior flaps and then close the opening into the vagina with catgut sutures. The clamps remained, as usual, forty-eight hours. Neither of these cases is numbered in this series of vaginal hysterectomies. Both recovered. In these sixty-six cases there was but one death. No alcohol was allowed to any of these patients either before, during or following the operations. My experience during the last twenty years, both with and without alcohol, leads me to believe that when other anesthetics are available surgical cases do far better without its administration. It will be noticed from the table that hypnotic suggestion was used in most of these cases as an aid to the anesthesia of chloro- form and ether. I regard suggestion as one of the